2.1. THE BEHAVIOUR
2.1.1. Terminology
The term self-harm is used in this guideline to refer to any act of self-poisoning or self-injury carried out by an individual irrespective of motivation (Hawton et al., 2003a). This commonly involves self-poisoning with medication or self-injury by cutting. There are a number of important exclusions that this term is not intended to cover. These include harm to the self arising from excessive consumption of alcohol or recreational drugs, mismanagement of physical health conditions, body piercing or starvation arising from anorexia nervosa. In the past, various other terms have been used including ‘parasuicide’ and ‘attempted suicide’ (Kreitman, 1977), the latter to describe self-harm in which the primary motivation is to end life. However, it became evident that motivation is complex and does not fall neatly into such categories. Terms such as ‘non fatal deliberate self-harm’ (Morgan et al., 1975) were preferred because they avoided making inferences about the motivation behind the behaviour. However, the word ‘deliberate’ is no longer preferred because it can be considered judgemental and it has been argued that the extent to which the behavior is ‘deliberate’ or ‘intentional’ is not always clear – those who harm themselves during a dissociative state often describe diminished or absent awareness of their actions at these times.
2.1.2. How common is self-harm?
Population estimates of the prevalence of self-harm in the community vary considerably. One cross-national study of 17 countries found that an average of 2.7% of people reported a previous episode of self-harm, but with considerable variation between 0.5% in Italy and 5% in the US (Nock et al., 2008). This variation may well reflect a person's willingness to report self-harm. In the UK, an adult psychiatric morbidity survey collected self-reported data on ‘attempted suicide’ and ‘self-harm’ (McManus et al., 2009), according to whether or not the person reported that they had intended to take their life. Overall 5.6% reported lifetime suicide attempts (6.9% of women and 4.3% of men) with 0.7% reporting this had occurred in the last year. Self-reported lifetime history of self-harm (without lethal intent) was slightly less common: 4.9% overall (5.4% of women and 4.4% of men). Self-harm can occur at any age but is most common in young people1.
In Meltzer and colleagues' survey (2001) of 12,529 children and young people aged 5 to 15 years, 1.3% had tried to harm themselves. Data in this survey was collected from parental interviews; when information is obtained directly from young people, rates are considerably higher. Hawton and colleagues (2002) conducted a questionnaire survey of 6,020 Year 11 pupils in the Oxford area. They reported that 13.2% of young people responding had self-harmed at some point in their lives, 6.9% in the previous year. Only 12.6% of those who had harmed themselves had presented to hospital, the vast majority of acts of self-harm being ‘invisible’ to professionals. Although rates of self-harm vary between countries (Madge et al., 2008), research in England, Canada and Australia between 2002 and 2005 indicated that the lifetime rate of self-harm in schools was 12 to 15% (De Leo & Heller, 2004; Ross & Heath, 2002). In contrast, only approximately 5% of all episodes of self-harm occur in people over the age of 65 (Dennis et al., 1997; Draper, 1996).
Much of the detailed epidemiological study of self-harm has been based in hospital settings and suggests self-harm might account for over 200,000 hospital attendances in England every year (Hawton et al., 2007). Recent data from Oxford, Manchester and Derby suggested that rates of hospital presentation for self-harm varied at between 400 and 550 per 100,000 per year for women and between 300 and 400 per 100,000 per year for men (Bergen et al., 2010a). Rates fell by between 8 and 21% over an 8-year period (from 2000 to 2007), with a more pronounced fall in men.
2.1.3. Methods of self-harm
Methods of self-harm can be divided into two broad groups: self-poisoning and self-injury. Although statistically there may be different motivations and intentions behind the method chosen (Sutton, 2007), there is a variety of individual and practical reasons that spans both groups. Assumptions cannot be made about motivation and intent based on the chosen method of self-harm and, indeed, there is good evidence that people often switch methods of self-harm (Lilley et al., 2008a)
Studies of attendance at emergency departments following self-harm show that approximately 80% of people have taken an overdose of prescribed or over-the-counter medication (Horrocks et al., 2003), most commonly analgesics or antidepressants. A small percentage of overdoses are of illicit drugs or other substances (for example, household substances or plant material). However, these figures can be misleading because people who self-poison are more likely to seek help than those who self-injure (Hawton et al., 2002; Meltzer et al., 2002). General population studies have shown that self-injury may be more common than self-poisoning (Hawton et al., 2002; Meltzer et al., 2001).
Of those who self-injure, cutting is the most common method (Hawton et al., 2002; Horrocks et al., 2003). Less common methods include burning, hanging, stabbing, swallowing or inserting objects, shooting, drowning, and jumping from heights or in front of vehicles.
2.1.4. Outcomes: repetition and suicide
Approximately one in five people who attend an emergency department following self-harm will harm themselves again in the following year (Bergen et al., 2010a); a small minority of people will do so repeatedly. The frequency with which some of the latter group self-harm means that they are over-represented among those who present at an emergency department or receive psychiatric care. There is no good evidence to support the widely-voiced opinion that people who harm themselves repeatedly, particularly by cutting, are less likely to die by suicide than those who harm themselves in other ways. Indeed one hospital-based study suggested that self-cutting increased suicide risk (Cooper et al., 2005). Repetition of self-harm may occur quickly with up to one in ten repeat episodes occurring within 5 days of the index attempt (Kapur et al., 2005).
The suicide rate in the general population varies across countries. In the UK in 2009, the suicide rate per 100,000 was 3.0 for females and 10.9 for males (World Health Organization, 2011). Following an act of self-harm, the rate of suicide increases to between 50 and 100 times the rate of suicide in the general population (Hawton et al., 2003a; Owens et al., 2002). Men who self-harm are more than twice as likely to die by suicide as women and the risk increases greatly with age for both genders (Hawton et al., 2003b). It has been estimated that one quarter of all people who die by suicide would have attended an emergency department in the previous year (Gairin et al., 2003). In a large long-term study of over 20 years, Runeson and colleagues (2010) found that certain methods of self-harm were associated with increased suicide risk. Hanging, strangulation and suffocation were associated with a six-fold increased risk of future successful suicide compared with self-poisoning (Runeson et al., 2010).
2.1.5. Why do people self-harm?
Self-harm does not often simply follow the wish to die. Those who self-harm may do so to communicate with others or influence them to secure help or care. They may self-harm to obtain relief from a particular emotional state or overwhelming situation (Hjelmeland et al., 2002).
One particular intention or motive might predominate or all might coexist. This means that a person who self-harms repeatedly might not always do so for the same reason each time, or by the same method (Horrocks et al., 2003). Assumptions about intent, therefore, should not be made on the basis of a previous pattern of self-harm; each act must be assessed separately to determine the motivation behind it. Failure to do this can result in the meaning of the act being misunderstood and an interpretation that the service user finds judgemental or dismissive. This will inevitably lead to a breakdown in the therapeutic relationship, as well as making it less likely that appropriate help will be offered at times when a person is at high risk of suicide.
Consistent with these differences in intention and motive, people who self-harm might have very different expectations about how health services should respond and what constitutes a good outcome. In particular, people who harm themselves as a way of relieving distress (through cutting, for example) might be compelled to do this as a coping strategy to prevent suicide. They are likely to continue to need to do this until they receive appropriate and sufficient psychotherapeutic interventions and support.
2.1.6. Motives for self-harm in young people
The Child and Adolescent Self-Harm in Europe (CASE) (Hawton & Rodham, 2006) study is the largest and most extensive study of self-harm in 15- to 16-year-olds in the community. The original study comprised seven countries including England; a modified version recently covered Scotland (O'Connor et al., 2009a). The method of self-harm most commonly reported in these studies was self-cutting.
Consistent with the clinical studies, the young people endorsed psychological pain motives more frequently than other motives. ‘Wanting to get relief from a terrible state of mind’, ‘wanting to die’, ‘wanting to punish oneself’ and ‘wanting to show how desperate one was feeling’ are the top four motives endorsed by young people across Europe (Hawton & Rodham, 2006; Madge et al., 2008; O'Connor et al., 2009a).
2.1.7. The meaning of self-harm
It can be difficult for people to understand how an apparently self-destructive act such as self-harm can serve a positive purpose or have meaning for people.
Following a qualitative study of 76 women, Arnold (1995) argued that self-harm ‘had evolved as a way of coping with unbearable feelings engendered by painful life experience.’ For the women who took part in the study, it served a range of purposes including relief of feelings, self-punishment, regaining control and communicating to others. Arnold (1995) suggests that:
successful approaches to helping someone overcome self-injury need to examine fully the purposes served for an individual and the alternatives which may need to be in place before they can leave self-injury behind.
Babiker and Arnold (1997) expand on the functions and meanings of self-harm thus: functions concerned with coping and surviving, functions concerned with the self, functions concerned with dealing with one's experience, functions concerned with self-punishment and sacrifice, and functions concerning relationships with others. Other models that explore the meaning of self-harm and may be useful to promote understanding in clinicians include ‘the eight Cs of self-injury’ (Sutton, 2007):
coping and crisis intervention
calming and comforting
control
cleansing
confirmation of existence
creating comfortable numbness
chastisement
communication.
2.1.8. Factors that are associated with self-harm
Demographics, socioeconomic factors and life events
Self-harm is more common in the young with the incidence peaking between the ages of 15 and 19 years in females and 20 and 24 years in males. Self-harm occurs in all sections of the population but is more common among people who are disadvantaged in socioeconomic terms and among those who are single or divorced, live alone, are single parents or have a severe lack of social support (Meltzer et al., 2002).
Life events are strongly associated with self-harm in two ways. First, there is a strong relationship between the likelihood of self-harm and the number and type of adverse events that a person reports having experienced during the course of his/her life. These include victimisation and, in particular, sexual abuse (Meltzer et al., 2002; O'Connor et al., 2009b). Second, life events, particularly relationship problems, can precipitate an act of self-harm (Haw & Hawton, 2008; O'Connor et al., 2010). Many people who self-harm have a physical illness at the time and a substantial proportion of them report this as the factor that precipitated the act (De Leo et al., 1999).
Some evidence suggests that a family history of self-harm may be a risk factor for repetition of self-harm. A large-scale cross-sectional study with over 6,000 participants conducted among young people in England (Hawton et al., 2002) reported that self-harm in family members was a risk factor for both males and females. Although this was based on students' self-reports resulting in possible ascertainment bias, this finding suggests there is an intergenerational transmission of risk, one explanation for which is genetic susceptibility. This hypothesis is supported by a large twin study with 5,995 participants based in Australia, which found that history of self-harm in a co-twin was strongly predictive of self-harm in monozygotic twin pairs but not in dizygotic twin pairs, suggesting that the heritability of suicidal thoughts and behaviours was in the region of 45% (Statham et al., 1998).
The association between self-harm and mental disorder
Most people who attend an emergency department following an act of self-harm will meet criteria for one or more psychiatric diagnoses at the time they are assessed (Haw et al., 2001). More than two thirds would be diagnosed as having depression although within 12 to 16 months two thirds of these will no longer fulfil diagnostic criteria for depression.
People diagnosed as having certain types of mental disorder are much more likely to self-harm (Skegg, 2005). For this group, the recognition and treatment of these disorders can be an important component of care. In one survey of a sample of the British population, people with current symptoms of a mental disorder were up to 20 times more likely to report having harmed themselves in the past (Meltzer et al., 2002). The association was particularly strong for those diagnosed as having phobic and psychotic disorders. People diagnosed as having schizophrenia are most at risk and approximately half of this group will have harmed themselves at some time.
Certain psychological characteristics are more common among people who self-harm, including impulsivity, poor problem solving, hopelessness, impaired positive future thinking/goal re-engagement, high levels of self-criticism and perfectionism (Brezo et al., 2005; MacLeod et al., 1997; O'Connor et al., 2009b; Slee et al., 2008). Also, people who self-harm more often have interpersonal difficulties. It is possible to apply diagnostic criteria to these characteristics. This explains why nearly half of those who present to an emergency department meet criteria for having a personality disorder (Haw et al., 2001). However, there are problems with doing this because:
The association between self-harm and alcohol and drug use
Approximately half of people who attend an emergency department following self-harm will have consumed alcohol immediately preceding or as part of the self-harm episode (Horrocks et al., 2003; Merrill et al., 1992). For many, this is a factor that complicates immediate management either by impairing judgement and capacity, or by adding to the toxic effects of ingested substances. Approximately one quarter of those who self-harm will have a diagnosis of harmful use of alcohol (Haw et al., 2001). Men are more likely to drink before an episode of self-harm than women (Hawton et al., 2003b) and are more likely to be misusing drugs or alcohol, as well as to have higher rates of several risk factors for suicide (Taylor et al., 1999). Substance misuse is associated with hospital admission for self-harm in inpatients discharged from psychiatric care (Gunnell et al., 2008).
The association between self-harm and child abuse and domestic violence
Child sexual abuse is known to be associated with self-harm (Fliege et al., 2009; Hawton et al., 2002; Meltzer et al., 2002), especially among people who repeatedly self-harm, as well as a range of mental health problems particularly in teenage years and adulthood for females, and for looked-after children (Meltzer et al., 2002). Physical abuse is also implicated in self-harm (Glassman et al., 2007; O'Connor et al., 2009a). Those who experienced bullying in childhood are at increased risk of future self-harm even after adjustment for the co-occurrence of other risks such as abuse (Meltzer et al., 2011). Experience of domestic violence (intimate partner violence) is a significant risk factor for self-harm. Compared with controls, in a retrospective cohort study, people suffering from domestic violence were more likely to present with self-harm than controls (Boyle et al., 2006). It is suggested that health-care professionals explore whether self-harm is an issue when there is evidence of domestic violence (Sansone et al., 2007).
It is important to note that socioeconomic factors such as unemployment and poverty, childhood experiences of abuse, and experiences of domestic violence are all associated with a wide range of mental disorders, as well as self-harm. How these experiences and factors interact needs to be explored and better understood.
The association between sexual orientation and self-harm
Growing evidence supports an association between sexual orientation and self-harm in men and women (O'Connor et al., 2009b; Skegg et al., 2003). In a recent systematic review and meta-analysis (including data from 214,344 heterosexual and 11,971 non-heterosexual people), lesbian, gay and bisexual people were at a heightened risk of self-harm compared with heterosexual people (King et al., 2008). The evidence for this association thus far is strongest for young people.
2.1.9. Special groups
Young people
The rate of self-harm is low in early childhood but increases rapidly with the onset of teenage years (Hawton et al., 2002). Hawton and Rodham (2006) conducted a school-based survey of 6,000 young people in Year 11 (aged 15 and 16 years) in Oxfordshire, Northamptonshire and Birmingham. The percentage of participants from the survey who reported having deliberately tried to harm themselves at some point in their lives was 13.2%, with 8.6% in the last year. Rates were higher in girls than boys both for lifetime (20.2 versus 7%) and for previous year (13.4 versus 4.4%). This anonymous survey also examined the factors associated with self-harm, coping strategies used and access to services (Hawton & Rodham, 2006). Self-harm is clearly related to interpersonal difficulties: younger teenagers describe family problems and older teenagers cite partner issues (Hawton et al., 2003a). Little is known about the problem of self-harm in younger children; however, there appears to be a difference in the female to male ratio with increasing age, from 8:1 females to males in 10- to 14-year-olds through 3.1:1 in 15- to 19-year-olds, to 1.6:1 in 20- to 24-year-olds (Hawton & Harriss, 2008a). One study found an overall self-harm rate of 29 per 100,000 (ages 10 to 19 years) (Clarke et al., 2000). An Oxford study comparing trends in self-harm between 1985 and 1995 found that the largest rise was in 15- to 24-year-old males (+194.1%) (Hawton et al., 1997).
Asian women
Husain and colleagues (2006) concluded that South Asian women are at an increased risk of self-harm. The demographic characteristics, precipitating factors and recent clinical management are different in South Asian compared with white women. South Asian women may be more likely to self-harm between the ages of 16 and 24 years than white women. South Asian women are less likely to attend the accident and emergency (A&E) department with a repeat episode of self-harm. Across all age groups, the rates of self-harm are lower in South Asian men compared with South Asian women. However, a more recent cohort study of 20,574 individuals from three UK centres found no increased risk in this group, instead reporting an elevated risk in young black women (Cooper et al., 2010).
Older people
Hawton and Harriss (2006) studied 730 people who were 60 years or older and had presented to hospital following self-harm. The authors found very high suicidal intent among this group and, at follow-up over 20 years, very high suicide rates (4.5%). Dennis and colleagues (2005) studied older people with depression, finding that two thirds had significant suicidal intent. Older people with depression who self-harmed were more likely to have a poorly integrated social network; loneliness and lack of support from services were identified as important factors in determining suicidal behaviour in older adults.
Lamprecht and colleagues (2005) examined self-harm in older people presenting to acute hospital services over 3 years. More males (56%) than females (26%) who presented with self-harm were married. The observations suggested an increase in self-harm in men, and marriage may no longer be a protective factor among older men.
Dennis and colleagues (2007) confirmed their previous finding that the majority of older people who harmed themselves had high suicidal intent and a high proportion (69%) were depressed. Individuals were frequently living alone with an isolated lifestyle and poor physical health. Barr and colleagues (2004) described four characteristics that have been shown to be associated with increased vulnerability in older people who self-harm: increased suicidal intent, physical illness, mental illness and social isolation.
People with a learning disability
Some genetic conditions associated with learning disability increase the likelihood that the individual with that condition will exhibit self-injurious behaviour (Gates, 2003). Wisely and colleagues (2002) identified that endogenous opioids produce a morphine-like effect that can account for the development of some forms of self-harm.
James and Warner (2005) argue that self-harm represents a significant yet poorly theorised area of concern with respect to women who have learning disabilities, particularly in the context of secure service provision. Their self-harm is meaningful and consideration should be given to how they understand and manage their experiences, cognitions and emotions.
2.1.10. Service provision for self-harm
There are no accurate figures for the number of presentations to emergency departments, but extrapolated from registers held at centres in the UK there are around 200,000 attendances in England annually (Hawton et al., 2003b). One hallmark of service provision for self-harm has been its variability, which has been consistent over time (Bennewith et al., 2004; Blake & Mitchell, 1978; Kapur et al., 1998). Studies have also suggested under provision with respect to self-harm services. In one study of 32 general hospitals in England, only just over half of episodes resulted in a specialist psychosocial assessment and the range was 36 to 82%. There was also considerable variation in psychiatric admission (overall 9.5%; range 2.5 to 23.8%), and mental health follow-up (overall 51%; range 35 to 82%) (Bennewith et al., 2004). Possible reasons for poor services include limited resources, a lack of an evidence base for treatments, and the unpopularity of this group of service users among some clinical staff (Kapur et al., 1999).
2.1.11. Professional attitudes to self-harm and service users' experience
People who self-harm often describe experiencing negative responses from staff in mental health services and emergency departments. This may be linked to professionals' lack of understanding of the behaviour (Arnold, 1995):
Professionals are often terrified by self-injury. Their normal empathy with others' distress and their confidence and ability to help often desert them when faced with someone who persistently hurts themselves. This problem reflects a serious and widespread lack of understanding of self-injury, which results in great inconsistency and inadequacies in services.
As part of writing NICE Clinical Guideline 16, Self-harm: the Short-term Physical and Psychological Management and Secondary Prevention of Self-harm in Primary and Secondary Care (NICE, 2004a; NCCMH, 2004), a series of focus groups were held with service users to establish their experience of professionals' attitude to self-harm. Service users mentioned approaches that they had found helpful and supportive, but also mentioned less positive responses.
Ramon and colleagues (1975) found that the lethality of self-harm is also an influencing factor on nursing and medical staff's attitudes towards self-harm, with sympathy and lethality being positively correlated. This finding was mirrored in a US study (Ansel & McGee, 1971) and an Australian study (Bailey, 1994), both of which found that positive attitudes were more likely to be displayed towards clearly suicidal or despairing patients.
2.2. TREATMENT AND MANAGEMENT IN THE NATIONAL HEALTH SERVICE
2.2.1. Detection, recognition and referral in primary care
Available figures suggest that up to 6.6% (Meltzer et al., 2002) of individuals seen in primary care may have a history of self-harm that may not be identified during the consultation. Some of the factors contributing to this include the narrow time constraints upon consultation time, which may not facilitate the development of a confiding relationship/atmosphere in which thoughts/acts of self-harm may be disclosed. Additionally, interactions with members of the primary care team will usually be task related and there is not a culture of routinely asking about self-harm, unless there are features suggesting this. Many healthcare professionals are not educated in risk factors for self-harm and may miss opportunities to detect it. Research interventions in primary care for those who have self-harmed have been made possible by proactive invitation of service users known to self-harm (Bennewith et al., 2002).
Young people who self-harm frequently come to the attention of school teachers and young people's health advisors. Whilst these staff often receive training in how to handle a young person disclosing that they self-harm, this aspect of work causes concern among staff who often request further training from local healthcare professionals. In some areas, schools – supported by child and adolescent mental health services (CAMHS) staff – provide universal interventions focused on the development of emotional literacy and coping skills, in an endeavour to decrease the likelihood of self-harm.
2.2.2. Assessment
Assessment should encompass both an assessment of risk and the wider context and needs of the service user. Assessment is intended to determine the type and intensity of future input required by the service user. One of the main challenges in assessment of risk post-self-harm is that there are no risk assessments that can accurately determine the likely risk of repetition. All measures are likely to class too many people at high risk of repetition and possible future death and to misclassify some people as low risk when in fact they are at high risk (Department of Health, 2007). Consequently, Self-Harm: the Short-term Physical and Psychological Management and Secondary Prevention of Self-harm in Primary and Secondary Care (NICE, 2004a) recommends that healthcare professionals do not use risk assessments alone to decide not to offer follow-up. Subsequent to assessment, the assessing clinician may recommend no follow-up, follow-up in primary care, referral to a community mental health team (CMHT) or crisis resolution and home treatment team, referral for psychological treatment or a recommendation for inpatient admission. In some areas psychiatric liaison teams may offer brief time limited follow-up (1 to 4 weeks) before discharge or referral on to the CMHT.
Young people
Young people, especially those under 16 years old, on presentation at emergency departments are likely to be admitted to the paediatric ward to await assessment by CAMHS prior to discharge. In some areas 17- to 18-year-olds may receive similar treatment, in others they may receive assessment under the protocol used for the treatment of adults. In other respects, their treatment will resemble that of adults; firstly addressing any medical issues before moving onto risk and psychosocial assessment. The outcomes following assessment will vary. Some young people will refuse further input from CAMHS, in part because the self-harm act and the response from the system may have resulted in at least a temporary resolution of the difficulties precipitating the behaviour. Others will accept an offer of further assessment or therapy, which is usually family-centred, although non-attendance at follow-up is a common problem with young people (Piacentini et al., 1995). A small proportion of young people may remain highly suicidal and need admission directly (within 24 hours) to inpatient psychiatric treatment in Tier 4, but this is often delayed. Depending upon the assessment of the relevant factors contributing to the episode of self-harm, some young people may be referred to Social Services under the Children Act (Her Majesty's Stationary Office [HMSO],1989 and 2004).
Assessment in secondary care services
Assessment for adults most commonly occurs in the context of the CMHT and will focus more broadly on the range of presenting problems of the service user. The team, as part of this initial assessment, will also conduct a risk assessment and are likely to develop an initial safety plan with the service user and/or carer. As part of the assessment, the team will consider the relationship between the self-harm and the other presenting problems of the service user. In some circumstances the team may not address a service user's self-harm actively as part of the treatment plan if it is believed that this is a result of a particular psychiatric diagnosis, for example depression. Rather, the focus will be on the primary psychiatric diagnosis. In other circumstances where the self-harm is potentially highly lethal, management of self-harm may form the centre of the treatment plan and service users may receive treatments that focus directly on reducing self-harm. These different treatment options and evidence relating to them will be discussed further in Chapter 7.
Whilst significant numbers of young people who self-harm may be managed by staff in Tier 1 (teachers, social workers and GPs), many young people who self-harm are referred for assessment to the Tier 3 CAMHS team. Young people who self-harm will receive an assessment of their wider presenting problems as well as an assessment of self-harm, encompassing an assessment of risk. Subsequent to this assessment, young people are likely to be offered a range of interventions that may or may not focus specifically on the self-harm.
2.2.3. Pharmacological treatments
Pharmacological treatments do not play a direct role in the management of self-harm; however, they have a significant indirect part to play in the management of associated conditions. Depression, anxiety disorders and schizophrenia are associated with a higher risk of self-harm, and the pharmacological treatment of these conditions is documented in their respective guidelines (NICE, 2009a, 2005b and c, 2011a and 2009b, respectively). There have been reports linking lithium treatment with a reduction in suicidal behaviour (Cipriani et al., 2005). Other coexisting conditions that may increase the risk of self-harm, such as chronic pain, may also lend themselves to pharmacological treatment (NICE, 2009c).
2.2.4. Psychological treatments
Self-harm is associated with a wide variety of psychiatric diagnoses and psychological problems. Psychological treatments offered to service users who self-harm differ to the extent to which self-harm is an explicit goal of the treatment. In routine clinical practice service users will receive a wide range of psychological interventions that may or may not focus primarily on their self-harm. Addressing self-harm may occur in series or in parallel with other interventions the service user is receiving. Treatments for self-harm are discussed in Chapter 7.
2.2.5. Harm reduction
For many service users a consideration of a ‘harm-reduction approach’ may be indicated. Whilst the concept and use of a ‘harm-reduction’ approach has been well established in relation to substance and alcohol misuse, the use of such an approach in relation to self-harm has been the focus of much controversy. It raises a number of complex and often inter-related clinical, ethical and legal issues, and requires careful consideration of a number factors, including: the meaning and function of self-harm for the individual; the importance of supporting the service user to achieve their own goals and retain their autonomy, dignity and responsibility wherever possible; the need to balance the risks associated with a harm reduction approach versus the risks associated with a ‘preventative approach’; and the application of potentially relevant legalisation (HMSO, 1983, 1989, 2004, 2005 and 2007a). Further discussion of this issue can be found in Chapter 7.
2.2.6. Risk and recovery
Following the publication of Our Health, Our Care, Our Say (Department of Health, 2006), choice and control are now considered critical components in the development of health and social care policy and practice. It is a policy that supports a ‘recovery-oriented’ approach, which aims to empower people to live a meaningful and purposeful life and promotes self-management (Shepherd et al., 2008).
Essentially, there is a need to ensure that any risk management plans are ‘defensible’ rather than ‘defensive’. The concept of ‘positive risk’ taking is highly relevant. This is an approach that both balances the service user's quality of life and safety needs of the service user, family, carers and public and considers the ‘potential benefits and harms of choosing one course of action over another’ (Morgan, 2004; Morgan, 2007).
2.2.7. Partnerships with other sectors
Individuals who self-harm may be involved with social care agencies and the voluntary sector in addition to involvement with healthcare services. In some areas staff from multiple agencies may work together to provide specific treatments or social care interventions particularly to support service users with long-standing histories of self-harm.
2.2.8. Looked-after children
Looked-after children and adolescents may demonstrate far higher levels of psychiatric diagnoses than children in the general population (Meltzer et al., 2001; Dimigen, 1999). Children are taken into state care for many reasons, the main being physical and sexual abuse by parents and/or associates. These traumatic experiences often lead to long-term psychiatric conditions and thus mental ill health. Interventions for this group of young people may be complex and might include securing longer-term placements.
2.2.9. Training
The majority of professionals working in secondary care will have received training in the assessment and management of risk associated with self-harm and suicidal behaviours. Despite this, clinicians frequently report high levels of anxiety around working with service users who self-harm and concern about working with high levels of risk. The ‘Better Services for People who Self-Harm’ project (Royal College of Psychiatrists, 2007) surveyed staff in ambulance services, emergency departments and mental health services regarding their need for training about self-harm. All groups of staff reported a need for further training with ambulance staff indicating the greatest need, but even many staff in mental health services felt under-trained in this area. Training in how to treat factors associated with high risk is less widely available and practitioners may rely on safety plans that focus on decreasing access to the means to self-harm and distraction or other crisis skills. Such strategies may help service users manage a short-term crisis but are unlikely to resolve more substantive issues leading to self-harm.
There is a range of training programmes developed for training healthcare professionals who work with people who self-harm, which are reviewed in Chapter 5.
2.3. ECONOMIC COSTS OF SELF-HARM
In addition to the physical and mental impact of self-harm on service users as well as their families and carers, self-harm imposes a significant economic cost both on the health sector and society in general. To date, no formal attempt has been made to quantify the total economic cost of self-harm within the UK. Because self-harm is associated with a range of mental disorders rather than a diagnosis, it is difficult to determine resource use and costs attributable directly to self-harm rather than any underlying cause (Sinclair et al., 2010a). However, it is clear that the assessment and management of self-harm incurs significant NHS resources, with 101,670 emergency department attendances recorded in 2008/09 due to self-harm (NHS Information Centre, 2009). This is probably a considerable underestimate – extrapolating from a study of three hospitals, Hawton and colleagues (2007) estimated there were 220,000 episodes dealt with by hospitals in England each year. Previously published studies have focused on the immediate costs of self-harm management rather than the wider costs involved in the longer-term management of self-harm (Sinclair et al., 2006).
A recent UK-based study retrospectively collected healthcare resource use from a cohort of people who self-harm recruited from a general hospital following an episode of self-harm (Sinclair et al., 2010a). The results of the study showed that a cumulative increase in the number of self-harm episodes was correlated with increased healthcare and social services costs within a 6-month period, particularly for service users who experienced five or more self-harm episodes. There was significantly more use of psychotropic medication and psychiatric care in those who harmed themselves five times or more during the 6-month study period. Care for service users with five or more episodes was characterised by high resource use of psychiatric services in the first 7 years after their first episode. Overall, total healthcare and social service costs were £3,524 (2004/05 prices) more per 6-month period for service users who self-harmed on five or more occasions compared with single episode service users. Within the year following the first ever episode of self-harm, inpatient and outpatient psychiatric services accounted for 69% and social services accounted for 19% of total costs. The results of the study highlighted a cumulative effect on healthcare costs, with increasing episodes of self-harm, particularly for service users with five or more episodes.
Byford and colleagues (2009) estimated the long-term costs, over 6 years, of a cohort of young people who participated in an RCT following an episode of self-poisoning. Lifetime and current (6-month) costs were calculated and compared with general population controls to explore costs incurred by the UK general public sector. Resource-use data included inpatient and day-patient services for psychiatric reasons, pregnancy or child birth, foster or residential care, supported accommodation, special education, prison and criminal justice, and social security benefits. Over the longer-term follow-up, the self-poisoning group used substantially more public sector resources in terms of special education, foster care, residential care or other supported accommodation, and social security benefits. They also spent more time in prison or police custody and had a number of hospital attendances for psychiatric reasons, in comparison with the general population control group. Lifetime differences in the costs of key services were large and statistically significant. The self-poisoning group incurred significantly more costs per year in terms of psychiatric hospital contacts, supported accommodation, special education and social security benefits. In total, the self-poisoning group cost over £1,500 per year compared with only £65 per year in the control group (mean difference £1,440; p < 0.001).
The indirect costs of self-harm in terms of lost productivity, days lost from work, as well as costs to families and carers are unknown but are likely to be substantial given its prevalence within the UK. Ensuring the efficient use of available healthcare resources will maximise the health benefits for people who self-harm and can potentially reduce costs to the UK healthcare system and society in the long term.
